While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record?
Left-sided heart failure
Myocardial ischemia
Right-sided heart failure is systemic and results in peripheral edema, weight gain, and distended neck veins
Atrial fibrillation
The Correct Answer is A
A. Left-sided heart failure: Left-sided heart failure causes pulmonary congestion leading to crackles, orthopnea (difficulty breathing while lying flat), and paroxysmal nocturnal dyspnea (waking up gasping for air).
B. Myocardial ischemia: Myocardial ischemia causes chest pain, shortness of breath, and fatigue, but it does not cause crackles in the lungs or fluid overload symptoms.
C. Right-sided heart failure: Right-sided heart failure results in systemic congestion (peripheral edema, weight gain, and jugular vein distention), not pulmonary symptoms like crackles.
D. Atrial fibrillation: Atrial fibrillation causes irregular heartbeats, palpitations, and fatigue, but it is not the primary cause of crackles or orthopnea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will administer the medications 10 minutes apart."Timing is important, but this option does not specify which medication should be taken first. The correct sequence is albuterol first, followed by cromolyn.
B. "I will use both medications immediately after exercising." Cromolyn is a mast cell stabilizer used for prevention, not acute symptoms. It should be taken 15-30 minutes before exercise to prevent exercise-induced bronchospasm, not after.
C. "I will be sure to take the albuterol before taking the cromolyn." Albuterol (a bronchodilator) should be taken first to open the airways, allowing better absorption of cromolyn (an anti-inflammatory medication).
D. "If my breathing begins to feel tight, I will use the cromolyn immediately." Cromolyn is not a rescue medication. Albuterol should be used for acute bronchospasm, while cromolyn is for long-term asthma control.
Correct Answer is ["C","D"]
Explanation
A. Nonproductive cough: Diphenhydramine is an antihistamine, not a cough suppressant. It does not cause a nonproductive cough as a side effect.
B. Drowsiness: First-generation antihistamines (like diphenhydramine) cause CNS depression, leading to drowsiness.
C. Urinary retention: Diphenhydramine has anticholinergic effects, which can lead to urinary retention, especially in older adults or those with prostate issues.
D. Dry mouth: Diphenhydramine blocks muscarinic receptors, reducing saliva production and causing dry mouth.
E. Skin rash: Skin rash is not a common adverse effect of diphenhydramine but can be a sign of an allergic reaction.
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